|
r aj
<br />W
<br />_Z Z�
<br />V\
<br />X
<br />rn
<br />c
<br />x D p
<br />n z
<br />TYPE OR PRINT WITll BLACK NK � I DATE
<br />G NOV O 2001
<br />DECEASED 1, NAME First
<br />2 D
<br />PErt of thy! Northwest Quarter (NWk) of Section Nine (9),
<br />Township Twelve (12) North, Range Nine (9) West of the 6th
<br />P.M., in Hall County, Nebraska, More Particularly Described
<br />as Follows:
<br />Co=encing at the Northwest Corner of Said Section 9 Thence
<br />N 89 °'51' 38" E40.00 Feet to the Point of Beginning; Thence
<br />Continuing on Said Bearing, N 89' 51' 38" E 2587.98 Feet Lu
<br />the North Quarter Corner of Said Section; Thence S 0° 05'
<br />18" E 581.74 Feet; Thence S 88' 52' 24" W 2588.82 Feet to
<br />the East Right -of -Way Line o£ U.S. Highway 281; Thence N I-
<br />, 19" W 627.04 Feet to the Point of Beginnin¢•,
<br />MISSISSIPPI STATE DEPARTMENT OF HEALTH
<br />VITAL RECORDS
<br />200112628
<br />s
<br />G
<br />CERTIFICATE OF DEATH STATE FILE 123.
<br />STATE OF MISSISSIPPI NUMBER
<br />Middle Last 12. SEX 3a. HOUR OF DEATH I 3b. DATE OF DEATH (Month, Day, Year)
<br />amm HENRY MOHR MALE __ I 630n. m. IQCT=R 31, 2001
<br />4. RACE (Specify White. Black. 5a. AGE AT LAST Y IF UNPER 1 YEA LY IF UNDER t D4 6. DATE OF BIRTH (Month, Day, Year) 7a. COUNTY OF DEATH
<br />American Indian, etc.) BIRTHDAY 5b. MOS 5c. DAYS 5d: HOURS 5e. MINS
<br />WHITE 6 Years ' F7;B 14 193 2 1 JACKSON
<br />7b. CITY OR TOWN OF DEATH 7c. HOSPITAL OR OTHER INSTITUTION-NAME AND NUMBER (If not in 7d. IF IN HOSP., OR INST. SPECIFY 8. STATE OF BIRTH
<br />If death occurred in either, give street address, route number or other location) INPT, OUTPT., EMER. RM,OR DOA
<br />an institution, see
<br />HANDBOOK regartling VANCLEAVE 2412 D.H. SMITH ROAD B
<br />eomPletioaof_ - - 9. DECEDENT'SEDUCATION Elem" h "ScK6bi Code - -- _ "10 "tiAAi9RiEt% NEVER MARR1ED 11 SURVIVING SPOUSE (Ifs ife, gv 12. WAS DECEASEEDDE R IN
<br />RESt4£t3C,E items (Specify only highest fi (�.4 WApOWED;�3t�Of�ED > ,marden nemeT �i1.S ARMED FORCES?
<br />grade Completed) (oat) -�, 5 +).. ,(SpbGf (Yes or No) yES
<br />13 ORIGIN OR DESCENT (Specify Cuban, 14, SOCIAL SECURITY NUMBER 15a. USUAL OCCUPATION (Kind of work do 15b. KIND OF BUSINESS OR INDUSTRY
<br />Afro- American, Mexican, etc.) most of working life)
<br />For RESIDENCE itor s AMERICAN 507 -36 -1665 ELECTR
<br />.rater W.&I location 16a. RESIDENCE -STATE 16b. COUNTY 16c. CITY OR TOWN 16d. INSIDE CITY LIMITS 16e. STREET AND NUMBER OR RURAL LOCATION
<br />of home aura then (Specify Yes or No)
<br />lilt p addr"` MI SISS] JACKSON VANCLEAVE NO 12412 D.H. SMITH ROAD
<br />PARENTS 17. FATHER -NAME First Middle Last 18. MOTHER -NAME First Middle Maiden
<br />PETER FREDRICK MOHR
<br />INFORMANT 19a. INFORMANT -NAME (Type or print) I 19b. MAILING ADDRESS (Street and number or route and box number, City or town, State, ZIP code)
<br />DISPOSITION
<br />c�
<br />n v)
<br />REMOVAL (Specify)
<br />.
<br />►-•
<br />o -4
<br />o
<br />21b. FUNERAL HOME -NAME AND MISSISSIPPI I.D. NUMBER 21c. MAILING ADDRESS (Street and number or route and box number, City or town, State. ZIP code)
<br />f
<br />Z -4
<br />N
<br />22a. PERSON WHO PRONOUNCED DEATH -NAME AND TITLE (Type or print) 22b. PRONOUNCED DEAD (Month, Day, Year)
<br />rri
<br />r>1
<br />c-�
<br />__j M
<br />C:D
<br />co
<br />"cam -
<br />23b. MAILING ADDRESS (Street and number or route and box number, City or town, State, ZIP Code)
<br />EDGAR W. HULL, M.D.
<br />DENNY AVE., PASCAGOULA, MS 39581
<br />_2809
<br />24a. To the best o1 my knowledge. tleath occurred due to the cause(s�
<br />o °
<br />o
<br />g
<br />°
<br />o
<br />,rT
<br />section ' SIGNATURE �
<br />to be com -'
<br />Board of Health
<br />pleted by t 24b. DATE SIGNED (WW. Day, Year) 24c. STATE LICENSE NUMBER
<br />plated by 124t. TITLE
<br />z m
<br />I--
<br />Cn
<br />.. ..
<br />examiner ' 24d. NAME OF': • ENDING PHYSICIAN IF OTHER THAN CERTIFIER --
<br />D 0�;
<br />v
<br />CAUSE OF DEATH
<br />r
<br />N
<br />C0121
<br />I DUE TO. OR AS A CONSEQUENCE OF (Enter one cause only): I Interval between onset
<br />Conditions, if any,
<br />I I and death
<br />which lave rise to
<br />(b) I
<br />immediate cause
<br />statinngg the
<br />DUE TO, OR AS A CONSEQUENCE OF (Enter one cause only): I Interval between onset
<br />r
<br />I - I and death
<br />cause laStr
<br />O
<br />Clt
<br />CSD
<br />=
<br />26. PARR II: OTHER SIGNIFICANT CONDITIONS- Conditions contributing to death but not resulting in the underlying cause
<br />AUTOPSY
<br />Cn
<br />•-"r
<br />given in PART I
<br />127.
<br />(Yes or No
<br />MEDICAL EXAMINER?
<br />been Pregnant
<br />130
<br />(Yes or No) no
<br />MISSISSIPPI STATE DEPARTMENT OF HEALTH
<br />VITAL RECORDS
<br />200112628
<br />s
<br />G
<br />CERTIFICATE OF DEATH STATE FILE 123.
<br />STATE OF MISSISSIPPI NUMBER
<br />Middle Last 12. SEX 3a. HOUR OF DEATH I 3b. DATE OF DEATH (Month, Day, Year)
<br />amm HENRY MOHR MALE __ I 630n. m. IQCT=R 31, 2001
<br />4. RACE (Specify White. Black. 5a. AGE AT LAST Y IF UNPER 1 YEA LY IF UNDER t D4 6. DATE OF BIRTH (Month, Day, Year) 7a. COUNTY OF DEATH
<br />American Indian, etc.) BIRTHDAY 5b. MOS 5c. DAYS 5d: HOURS 5e. MINS
<br />WHITE 6 Years ' F7;B 14 193 2 1 JACKSON
<br />7b. CITY OR TOWN OF DEATH 7c. HOSPITAL OR OTHER INSTITUTION-NAME AND NUMBER (If not in 7d. IF IN HOSP., OR INST. SPECIFY 8. STATE OF BIRTH
<br />If death occurred in either, give street address, route number or other location) INPT, OUTPT., EMER. RM,OR DOA
<br />an institution, see
<br />HANDBOOK regartling VANCLEAVE 2412 D.H. SMITH ROAD B
<br />eomPletioaof_ - - 9. DECEDENT'SEDUCATION Elem" h "ScK6bi Code - -- _ "10 "tiAAi9RiEt% NEVER MARR1ED 11 SURVIVING SPOUSE (Ifs ife, gv 12. WAS DECEASEEDDE R IN
<br />RESt4£t3C,E items (Specify only highest fi (�.4 WApOWED;�3t�Of�ED > ,marden nemeT �i1.S ARMED FORCES?
<br />grade Completed) (oat) -�, 5 +).. ,(SpbGf (Yes or No) yES
<br />13 ORIGIN OR DESCENT (Specify Cuban, 14, SOCIAL SECURITY NUMBER 15a. USUAL OCCUPATION (Kind of work do 15b. KIND OF BUSINESS OR INDUSTRY
<br />Afro- American, Mexican, etc.) most of working life)
<br />For RESIDENCE itor s AMERICAN 507 -36 -1665 ELECTR
<br />.rater W.&I location 16a. RESIDENCE -STATE 16b. COUNTY 16c. CITY OR TOWN 16d. INSIDE CITY LIMITS 16e. STREET AND NUMBER OR RURAL LOCATION
<br />of home aura then (Specify Yes or No)
<br />lilt p addr"` MI SISS] JACKSON VANCLEAVE NO 12412 D.H. SMITH ROAD
<br />PARENTS 17. FATHER -NAME First Middle Last 18. MOTHER -NAME First Middle Maiden
<br />PETER FREDRICK MOHR
<br />INFORMANT 19a. INFORMANT -NAME (Type or print) I 19b. MAILING ADDRESS (Street and number or route and box number, City or town, State, ZIP code)
<br />DISPOSITION
<br />20a. BURIAL, CREMATION. I 2Db. CEMETERY, CREMATORY -NAME 20c LOCATION (City and State)
<br />21a. EMBALMER - SIGNATURE AND NUMBER
<br />REMOVAL (Specify)
<br />.
<br />C
<br />( not emba l mpj )
<br />21b. FUNERAL HOME -NAME AND MISSISSIPPI I.D. NUMBER 21c. MAILING ADDRESS (Street and number or route and box number, City or town, State. ZIP code)
<br />' F.H. I P.O. BOX 133, BILOXI, MISSISSIPPI 39533
<br />PRONOUNCEMENT
<br />22a. PERSON WHO PRONOUNCED DEATH -NAME AND TITLE (Type or print) 22b. PRONOUNCED DEAD (Month, Day, Year)
<br />I 22c. PRONOUNCED DEAD
<br />ON OCTOBER 31, 2001
<br />ATou850p. m.
<br />CERTIFIER
<br />23a. CERTIFIER -NAME (Type or print)
<br />23b. MAILING ADDRESS (Street and number or route and box number, City or town, State, ZIP Code)
<br />EDGAR W. HULL, M.D.
<br />DENNY AVE., PASCAGOULA, MS 39581
<br />_2809
<br />24a. To the best o1 my knowledge. tleath occurred due to the cause(s�
<br />e4 . On the basis of examination and/or investigation, in my opinion, death
<br />This I and manner as star
<br />This occurred due to the cause(s) and manner as stated.
<br />Mississippi State
<br />section ' SIGNATURE � MD
<br />to be comJ -
<br />section ' SIGNATURE �
<br />to be com -'
<br />Board of Health
<br />pleted by t 24b. DATE SIGNED (WW. Day, Year) 24c. STATE LICENSE NUMBER
<br />plated by 124t. TITLE
<br />Form No. 511
<br />Revised 1 -1.89
<br />physician I ^^
<br />if I b V ' fY O G.. ` 06293
<br />medical I
<br />epNLYner I
<br />.. ..
<br />examiner ' 24d. NAME OF': • ENDING PHYSICIAN IF OTHER THAN CERTIFIER --
<br />' 24g. DATE SIGNED (Month, Day. Year)
<br />(Type or prirli)
<br />CAUSE OF DEATH
<br />25. IMMEDIIAAT�Ey,C�AUSE (Enter one cause only): I tween onset
<br />DEATH a'dLdevabh
<br />USED (a) l.I'IltCIA,0j- f-�% y \� 1 Q 0STIA "f !C'P7RS
<br />BY:
<br />I DUE TO. OR AS A CONSEQUENCE OF (Enter one cause only): I Interval between onset
<br />Conditions, if any,
<br />I I and death
<br />which lave rise to
<br />(b) I
<br />immediate cause
<br />statinngg the
<br />DUE TO, OR AS A CONSEQUENCE OF (Enter one cause only): I Interval between onset
<br />underying
<br />I - I and death
<br />cause laStr
<br />I (C) I
<br />26. PARR II: OTHER SIGNIFICANT CONDITIONS- Conditions contributing to death but not resulting in the underlying cause
<br />AUTOPSY
<br />28. WAS CASE REFERRED TO
<br />Had Decedent
<br />given in PART I
<br />127.
<br />(Yes or No
<br />MEDICAL EXAMINER?
<br />been Pregnant
<br />130
<br />(Yes or No) no
<br />Within 90 Days
<br />Use if 29a. ACCIDENT, SUICIDE. HOMICIDE, PENDIN 29b. DATE OF INJURY 29c. HOUR OF INJURY, 29d. DESCRIBE HOW OR BY WHAT MEANS INJURY OCCURRED
<br />death I INVESTIGATION. OR UNDETERMINED Day, Year)'
<br />Ptior to Death?
<br />(Month,
<br />Nero I (Specify) I t m. I
<br />129e. INJURY AT WORK 29f. PLACE OF INJURY (Specify Home, Farm, Street, 29g. LOCATION Street or route number City or town State
<br />I
<br />ireS NO
<br />causes (Yes or No) i Factory. Office building, etc.)
<br />I
<br />THIS IS TO CERTIFY THAT THE ABOVE IS A TRUE AND CORRECT COPY OF THE CERTIFICATE ON FILE IN THIS OFFICE
<br />(�
<br />,00,OV% TAT ; . :. Q� � F. E. Thommps r M D, M.PH , %$6
<br />Judy Moulder
<br />o STATE HEALTH OFFICER STATE REGISTRAR @� h C
<br />A REPRODUCTION OF TH13.DOCUMENT RENDERS IT VOID AND INVALID DO NOT ACCEPT UNLESS ,
<br />• r� • ,,��
<br />WARNING: EMBOSSED SEAL OF THE MISSWPPt STATE BOARD OF HEALTH W PRESEkIi IT IS IU.EGAL T(1 ALTER • ••
<br />"' ri„ %;. ✓ l��a
<br />'T2
<br />MEN c iii %; i, , i,m
<br />'� HIE �
<br />
|